Tag Archives: FPIES

Recently, one of our allergy-immunology colleagues, Dr. Kiran Patel, from Emory presented an update on GI Diseases from an allergist viewpoint at one of our GI clinical education meetings. With his permission, many of the slides are noted below. The slides present a good deal of information, though a lot of nuance and further details were provided by Dr. Patel.

Next few slides discuss typical GI food allergies. It is not surprising that a lot of allergies manifest with GI symptoms given the amount of immune cells in the intestines and frequent interactions with foods and antigens.

This next slide points out that four of the most common food allergens (cow’s milk, egg, soy, and wheat) are frequently outgrown, whereas with peanuts, tree nuts, fish, and shellfish, it is uncommon to outgrow these allergies..

The next slide discusses potential evaluation. While the slide states that the positive predictive value of skin prick tests and serum-based IgE tests may be as high as 50%; in fact, when broad panels of allergy tests are ordered, the positive predictive value can be quite low.

The last part of Dr. Patel’s talk focused on GI disease (eg. inflammatory bowel disease presentation) of primary immune deficiencies. In the bottom slide, the diseases that often present with GI symptoms are boxed.

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and changes in diet should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

#4. “Consider specific IgE testing of children with FPIES to their trigger food because comorbid IgE-mediated sensitization to triggers, such as CM [cow’s milk], can infer a greater chance of persistent disease.”

#8. Conduct food challenges “in patients with suspected FPIES in medically supervised settings in which access to rapid fluid resuscitation is available and prolonged observation can be provided, if necessary.”

#14. Do not routinely obtain endoscopic evaluation as part of the evaluation of FPIES.

#17. Acute FPIES should be considered a medical emergency. “Approximately 15% of patients can have hypovolemic shock.”

#21. Do not recommend routine maternal dietary elimination of offending triggers while breast-feeding if the infant is asymptomatic.

#23. FPIES can occur to multiple foods. “The majority of children (65% to 80%) have FPIES to a single food, most commonly CM.” In one study, 5% to 10% of children reacted to more than 3 foods.

#26. Use hypoallergenic formula in infants who can no longer breast-feed and are given a diagnosis of FPIES caused by CM. Most will tolerate extensively hydrolyzed formulas; some may require an amino acid based formula

#29. Reviews natural history. “The age of CM tolerance appears to be around 3 years” but there has been variability in reports. For FPIES due to grains, average age of tolerance is 35 months and other solid foods is 42 months. The average age for soy is 12 months (later in some studies), for rice 4.7 years and 4.0 years for oats. For CM-FPIES with positive SPT response, a much protracted course has been reported, with older age of tolerance (~13.8 years)

With regard to inborn errors of metabolism, these include urea cycle defects, hereditary fructose intolerance, hyperammonemic syndromes, Beta-oxidation defects, proprionic/methylmalonic academia, mitochondrial defects and others. Typically, features could include developmental delay, neurologic manifestations, organomegaly, and in some reaction to fruits.

Table IV specifies diagnostic criteria with the major criteria for acute FPIES: vomiting 1- to 4-h period after ingestion of the suspect food and absence of classic IgE-mediated allergic skin or respiratory symptoms. Minor criteria include extreme lethargy, pallor, need for emergency room evaluation/IV fluids, and diarrhea in 24 h (usually 5-10 h).

Table IX provides empiric guidelines for selecting weaning foods in infants with FPIES. The recommendations need to be considered based on whether the infant has shown tolerance for a number of foods, which can indicate the acceptability of a more liberal approach. Age-specific guidance:

Overall, with regard to food introduction: While children with FPIES have increased reactions to other foods, “current early feeding guidelines do not recommend delay in introducing complementary foods past 6 months of life because of FPIES. A practical ordering for introducing solids at about 6 months of age at home could start with fruits and vegetables.” For infants with history of severe reactions, “supervised (eg. in-office) introduction can be considered…and prevent unnecessary avoidance.” As with new foods in the home setting, starting with small amounts is recommended and then gradual build up in serving size.

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Variable time to resolution (Table E6): Cow’s milk resolution up to 60% resolution by 10 months, though some studies report 60% resolution at 3 years. Soy resolution as much as 90% by 10 months of age (less in other studies). Solids -resolution in 67% by 3 years.